Individual and Family Health Coverage
from Horizon Blue Cross Blue Shield of New Jersey
Plan Decision
Guide
• Horizon Basic and Essential EPO and EPO Plus
• Horizon HMO
• Horizon Direct Access
Also Inside: Enrollment Form
HORBR274 (W062012)
Individual and Family
Health Coverage
from the State’s Leading Health Insurer:
Horizon Blue Cross Blue Shield of New Jersey
Put our coverage advantages to work for you
with a plan that meets your needs and fits your budget.
For over 75 years, we’ve been helping New Jersey residents
with their health care coverage needs. Today, nearly 3.6 million
members have come to us for reliable coverage and the security of the
Blue Cross and Blue Shield name. Our strength, experience, and dependable
plans have helped make us the largest health insurer in New Jersey. This guide
includes just a few of the advantages you’ll find when you choose individual health
coverage from Horizon Blue Cross Blue Shield of New Jersey.
Table of Contents
Page
Introduction2
Before Choosing a Plan
3
Horizon Basic and Essential EPO and EPO Plus Plans
4
Horizon HMO Plans
5
Horizon Direct Access Plans
6
Enjoy Added Savings
7
Plan Exclusions
8
Premium Rate Sheet/Enrollment Forms
(see back pocket)
Plan Decision Guide
1
A Variety of Plan Choices for
Individuals and Families
Horizon Blue Cross Blue Shield of New Jersey is
pleased to offer a full range of health plan choices for
individuals and families. Whether you are purchasing
a health insurance plan for the first time or simply
looking to get more for your premium dollar, we’re
confident you’ll find a plan that fits your exact needs
and budget. Plus, you’re free to examine the coverage for
30 days with no risk or obligation. If you’re not satisfied
with the policy for any reason, simply return the policy to
us within 30 days. We’ll refund any premiums, less any
claims paid.
Access to broad
provider network
With our plan choices, you have access to the large
Horizon Managed Care Network. Our agreements
with these participating doctors and specialists allow
you to save on the premiums and the cost of covered
services. Dozens of leading institutions
recognize Horizon Blue Cross Blue
Shield of New Jersey and accept
our coverage with no paperwork
required. It’s likely that the
doctors and hospitals you
currently use participate in
our network.
Guaranteed renewability
Once coverage goes into effect, it is guaranteed
renewable. This means that, as long as your premiums
are paid on time, your coverage will renew each year
without proof of good health. Some limitations apply.
Coverage away
from home
No matter which plan you choose, medical emergencies
are covered at the in-network level for members while
traveling outside of the Horizon Managed Care Network.
The individual Direct Access plans also cover eligible
non-emergency medical services at the out-of-network
level while members are outside of the Horizon Managed
Care Network.
To maximize eligible out-of-network benefits while
traveling outside of the Horizon Managed Care
Network, Horizon Direct Access members
also have the option of using our
BlueCard Traditional Network. To
learn more about the services
available to you through the
BlueCard Traditional Network,
simply call the number on
the back of your card.
Available
prescription drug
coverage with
selected plans
The high costs for outpatient
prescription drugs are a
concern for many New Jersey
residents. That’s why most of
our plan options include coverage
to help cover the costs of commonly
prescribed medications.
2
Horizon Blue Cross Blue Shield of New Jersey
What You Need to Know
Before Choosing a Plan
We understand that every individual
and family has unique needs. That’s
why we want to make it as easy as
possible to choose the plan that works
for you and your budget. So, before you
sign up for a plan, be sure that you understand your options, based on important factors
like eligibility, payment options, and changing plans.
Eligibility
Under New Jersey law, you are eligible for health
insurance coverage regardless of your medical
condition, age, sex, occupation or where you live in the
state. However, you must be a New Jersey resident.
You or any dependents you wish to enroll must not be
covered or eligible under:
• Another individual health benefits plan
•
A group health benefits plan that provides
the same or similar coverage (as that phrase
has been interpreted through regulation)
• Medicare
Eligible dependents include your spouse, domestic partner
or civil union partner, and your children (including those
in your legal custody and guardianship) who are under age
26. Special rules apply to the continuation of coverage
beyond age 26 for handicapped children.
How to apply
Simply complete the enclosed enrollment form. To
save time in processing, be sure to answer all questions
carefully and completely for yourself and all eligible
dependents. Be sure to indicate your choice of plan and
deductible or copayment, if applicable.
Payment options
You may pay your initial premium by credit card. Monthly
premiums may be paid by automatic monthly bank draft
or direct bill each month. If paying by
direct bill, please enclose a check or
money order for your first month’s
premium. If choosing automatic monthly
bank draft, please attach a voided check to
your enrollment form.
Changing plans?
If you have health insurance with us or another
company, you need to know the following information
when changing plans:
From group coverage…
If you are eligible for group coverage, you can only
enroll in individual coverage that is not the same or
similar to your group coverage during the November
open enrollment for a January 1 effective date. Your
group coverage termination must coincide with the
effective date of your new policy with us.
From individual coverage...
If you already have coverage under an individual plan
offered by Horizon Blue Cross Blue Shield of New Jersey
or another carrier, restrictions may apply to changing
coverage. Please call your agent, broker or a Horizon
BCBSNJ Sales Representative at 1-888-425-5611 for
more information.
Questions about applying
or changing plans?
Need more information?
Feel free to call your agent or broker—or call us
toll-free at 1-888-425-5611, Monday through Friday,
from 8:30 a.m. to 5:00 p.m. ET.
If you have a hearing impairment, call our
telecommunication device at 1-800-852-7899.
You can also visit us online at www.HorizonBlue.com
Plan Decision Guide
3
Horizon Basic &
Essential EPO and
EPO Plus Plans
Horizon HMO Plans
Benefits Overview*
An HMO is a Managed Care plan, which gives you
the freedom of comprehensive coverage and more
out-of-pocket savings. You get to choose your
Primary Care Physician (PCP) from our extensive
physician network in New Jersey.
Horizon HMO Plans Offer:
Benefits Overview*
If affordability is what you’re looking for, these plans
offer some great options. Basic coverage can be a
good choice for those who would otherwise be
without health insurance because of the high cost
of comprehensive coverage.
• A
choice of copayment options starting
as low as $15
Benefit highlights:
An ideal option for people on a limited budget—
like recent college grads or the unemployed.
•Physician Services­—Primary Care
and Specialists
• Out-of-hospital diagnostic tests**
•Outpatient hospital services—outpatient
surgery and ambulatory surgery
• Inpatient hospital services
• Emergency room services
• Physical therapy
How does it work?
• Home health care
To receive coverage, you must use physicians,
hospitals, and health care professionals who participate
in the Horizon Managed Care Network. Seeing the
specialists you want is easy, since you don’t have to
select a Primary Care Physician and you don’t need a
referral. Out-of-network coverage is only provided in
cases of medical emergencies.
•EPO Plus also includes Prescription
Drug benefits
Horizon Basic and Essential EPO and EPO Plus
plans offer:
• Affordable premiums
•
No Primary Care Physician required
and no referrals needed
•
Health care services through the Horizon
Managed Care Network, plus out-of-state
medical emergency coverage
• And more
•
Low out-of-pocket costs with health care
services received through a Primary Care
Physician (PCP)
•
Extensive HMO network of physicians
and hospitals, plus out-of-state medical
emergency coverage
How does it work?
You must choose a physician as your Primary Care
Physician, who will be your main contact for medical
care, and referrals are needed to see specialists and
ancillary providers. By combining cost-saving features
and comprehensive coverage, HMO plans offer an
affordable alternative that is very popular among
New Jersey residents—particularly among those
with families.
Benefit highlights:
The extensive HMO network makes it easy and
affordable to get access to comprehensive care,
making it a popular choice among families.
•Your choice of a Primary Care Physician
(PCP) from an extensive Managed Care
network
•Outpatient hospital services—outpatient
surgery and ambulatory surgery
•Inpatient and emergency room coverage
• Home health care
• Physical therapy
• Prescription Drug coverage
• Much more
* Keep in mind that this is a general overview of some of the benefits provided by these
types of plans. Once you are enrolled, a complete list of details and exclusions will be
provided in your individual contract/policy.
**For diagnostic services rendered in the office, freestanding or an
outpatient facility.
*K
eep in mind that this is a general overview of some of the benefits provided by these
types of plans. Once you are enrolled, a complete list of details and exclusions will be
provided in your individual contract/policy.
4
Horizon Blue Cross Blue Shield of New Jersey
Plan Decision Guide
5
Horizon Direct Access Plans
Benefits
Overview*
Horizon Direct Access provides comprehensive coverage.
No referrals are required to access the physicians,
specialists, hospitals and other health care professionals
in the Horizon Managed Care Network. Choosing a
Primary Care Physician is recommended for maximum
benefits and medical care guidance, but is not required.
You also have the freedom to choose any physician or
hospital outside of the network, but will see significant
out-of-pocket savings by staying in-network.
Horizon Direct Access Plans Offer:
• L
ower out-of-pocket costs and higher
plan benefits by using providers and hospitals
in the Horizon Managed Care Network
•
No Primary Care Physician selection
or referrals required
•
Nationwide and worldwide access to medical
care through the BlueCard® PPO program
How does it work?
With this type of plan, you’re free to choose any
physician or hospital you wish. You’ll save more
money, however, if you choose to receive care from
doctors in the Horizon Managed Care Network. This
plan is popular among those who prefer the freedom
to see any specialist or provider without needing to get
a referral from a Primary Care Physician.
*K
eep in mind that this is a general overview of some of the benefits provided by these
types of plans. Once you are enrolled, a complete list of details and exclusions will be
provided in your individual contract/policy.
Benefit highlights:
A comprehensive health plan, offering
coverage for a wide range of services, plus
maximum freedom of choice.
•Access to in-network and out-of-network
providers and hospitals
•Virtually no claims to file
•Inpatient, outpatient, and emergency
room coverage
•Ambulatory surgical center coverage
•Home health care
•Maternity and preventative care
•Physical therapy
• And more
Enjoy Added Savings
on Products and Services Made
Available by Horizon
Horizon Blue Cross Blue Shield of New Jersey works hard to keep you
healthy with important savings on products and services beyond your
health care coverage. Once a member, you are eligible for discounts on
health-related products and services through our national discount
program, Blue365®. To access your Blue365 discounts, present your
Horizon BCBSNJ ID card at the participating business, or mention that you
are a Horizon BCBSNJ member when calling them.
Health Care Resources
Health Care Providers—To improve your peace of mind,
Blue365 can help you find quality care when you need it most.
Hearing and Vision Care—We’ve brought together these
resources and special offers to help you find and save on
quality hearing and vision care from vendors such as:
BeltoneTM, TruHearing®´´, Smart Eyes®´´, Davis Vision®´´,
HearUSA®´´, TruVision®´´, LasikPlus®´´, and QualSight Lasik®´´.
Insurance Tips—We know finding the right coverage can
get confusing. Blue365 is here to answer your questions and
simplify your decisions.
Prescriptions and Supplies—Find the medications, products
and information you need to stay healthy.
Healthy Choices
Fitness­—Find a fitness plan that works for you by taking
advantage of discounts offered by vendors such as: Anytime
Fitness®´´, Healthways Fitness Your WayTM, Snap FitnessTM,
Reebok®´´, Polar®´´, JCC®´´, and YMCA®´´. Or get stepping with
our Walking Works® plan, a self-directed program that lets
you customize your plan and track your progress online.
Weight Control—When you’re managing your weight and
aiming for better nutrition, you deserve all the support you can
get. Take advantage of discounts offered from vendors such as:
Jenny Craig®´´, Weight Watchers®´´´´, Nutrisystem®´´, eDiets®´´.
Alternative Therapies—With your membership to
HealthwaysTM, gain access to a network of over 40,000
health and wellness specialists, including chiropractors,
acupuncturists, massage therapists, personal trainers and
more, at discounts up to 30 percent.
Children—Let Blue365 help you keep your children safe
with support and guidance, as well as resources offered
by Hope Paige Medical®´´ (emergency jewelry), Safe
Beginnings®´´ (safety products) and Corcell®´´ (umbilical cord
blood banking).
†
6
Horizon Blue Cross Blue Shield of New Jersey
Food and Nutrition—
The quickest way to a
healthier diet is through the
brain. These resources make it
easy to understand how to eat right.
Wellness—Find the support you need to make healthy
choices every day and throughout your life. Access helpful
information that speaks to your unique needs, as well as
discounts from wellness vendors such as Anytime HealthTM.
Medicare—From navigating the Medicare maze to finding
the right care for an older loved one, Blue365 offers support
and information for the health needs of seniors. You can also
access discounts from vendors such as Seniorlink CareTM,
which offers unbiased reference information about your
eldercare and caregiver options and professional advisory
services, and MedicAlert Foundation®´´´.
Recreation and Travel
Blue365 gives you access to the best educational resources
and great savings on healthy travel and leisure experiences
such as spa vacations and wellness getaways.
Travel Healthy—Enjoy discounts from Fairmont Hotels and
Spas®´´on accommodations, spa treatments, healthy menus
and more.
Outdoor Recreation—Outdoor activities help keep your
body and your mind at their fittest. Explore a library of
outdoor safety tips, federal recreation, camping and tour
information and more.
Destination and Travel Tips—Get helpful information from
Blue365 wherever your travel plans take you.
Arts and Entertainment—These resources can help you get
healthier and have fun when doing it.
lease note: Discount programs are not insured. They are “value-added” features and may be terminated or changed without notice. Horizon BCBSNJ assumes no responsibility for any
P
circumstances arising out of the use, misuse, interpretation or application of any information, products or services provided by or made available by the companies specified herein
offering information, products, or services to you through Horizon Wellness Discounts. Horizon Wellness Discounts are made available for your convenience and do not constitute or
imply endorsement of the companies, their information, products or services by Horizon BCBSNJ.
Services and products provided by Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc., an independent licensee of the Blue Cross and
Blue Shield Association.
® Registered marks of the Blue Cross and Blue Shield Association.
®´/SM Registered and service marks of Horizon Blue Cross Blue Shield of New Jersey.
SM´ Registered mark of SmartEyes.
®´´ Complete Advantage name is a registered trademark of Davis Vision.
Healthyroads, Inc., is a subsidiary of American Specialty Health Incorporated (ASH).
© 2012 American Specialty Health Incorporated.
®´´´ MedicAlert is a federally registered trademark and service mark.
®´´´´ WEIGHT WATCHERS is the registered trademark of Weight Watchers International Inc.
© 2012 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.
Plan Decision Guide
7
Pre-existing Condition Limitation
Only Applies to Individuals
Age 19 and Older
Pre-existing Conditions Limitation
Definition of a “pre-existing” condition:
Exceptions to the limitation:
A “pre-existing” condition is an illness or injury that
manifests itself in the six months before your enrollment
date and for which in the six months prior to your
enrollment date:
The pre-existing condition limitation does not apply to
any individual under age 19 and to genetic information,
in the absence of a diagnosis of the condition related to
that information.
• you see a doctor, take prescribed drugs or receive
other medical care or treatment, or
This limitation may not apply if you transfer from another
health insurance plan and there has been no more than
a 31-day lapse in coverage. The limitation also does not
apply to Federally Defined Eligible Individuals who apply
for coverage within 63 days of termination of prior
coverage. Additional
limitations and
exclusions
may apply.
• you have had medical care or treatment
recommended to you by a doctor, or
• an ordinarily prudent or careful person would have
sought medical advice, care or treatment.
A pregnancy that exists on the effective date of your
coverage is also a pr­e-existing condition. However,
complications of pregnancy, as defined in N.J.A.C.
11:1-4.3, are not considered pre-existing conditions and
are not subject to the pre-existing condition limitation.
­­
How does this limitation affect coverage?
If this limitation applies, no benefits will be paid for
charges incurred for the covered person’s pre-existing
condition until 12 months after the enrollment date.
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